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Publications and Forms

2011 Workforce Diversity Plan

The plans and policies of the Department of Labor and Industrial Relations regarding equal employment opportunity to applicants without regard to race, color, religion, sex, age, national origin, political belief, veteran status, and physical or mental disability.

Affidavit for Security Release (WC-264)

A sample affidavit for former self-insured employers requesting release of security.

Affidavit for Security Release - Group Trusts (WC-264-G)

A sample affidavit for former self-insured group trusts requesting release of security.

Affidavit of Exemption for Workers' Compensation Insurance (WC-134)

An affidavit that construction industry business owners who are not required to purchase workers’ compensation insurance may use to aid them in obtaining business licenses from some cities and counties.  Note: This form should not be sent to the Division of Workers’ Compensation.

Application for Authority to Self-Insure (WC-81)

The application to be completed by an employer applying to individually self-insure.

Application for Consultation Service Form (LS-25)

An application for a Missouri On-Site Safety and Health Consultation.

Application for Group Self-Insurance (WC-81A)

The application to be completed by a group of employers applying to form a self-insured group trust.

Auditing Procedures for Applicants for Individual Self-Insurance (WC-130-AI)

The safety auditing procedures for those employers applying to individually self-insure.

Authorization for Release of Confidential Information (WC-249-3)

An authorization for release of confidential information that must accompany the Irrevocable Letter of Credit (WC-249).

Bond of Employer Carrying His Own Risk (WC-82B)

A Surety Bond; one of three options available to meet the self-insurance security requirement.

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